a of the

Ge Junction

Kiyanda BaldwinSUNY Downstate Medical CenterMorbidity & Mortality Conference

Kings County HospitalJune 10, 2010

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CASE PRESENTATIONThis is a 69 y/o man who presented to KCH 3/10 w/

CC of worsening dysphagia

• HPI:▫ Dysphagia since 12/09▫ 20lb weight loss▫ Diagnosed in 2/10 in St. Lucia w/ gastric

adenocarcinoma extending into distal esophagus ▫ Denied h/o GERD, melena, hematemesis

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• PMH: BPH

• PSH:TURP ‘06

• Meds:denies

• All:NKDA

• SH:denies tobacco, alcohol, or drug use, works as electrician, runs 1 mile & swims daily

• FH: noncontributory

CASE PRESENTATIONdownstatesurgery.org

• Vitals:

▫ T=98.8; BP= 134/80; HR=55; RR=20; 100%

• Gen: healthy, well built

• HEENT: WNL

• CVS: S1S2 RRR

• Chest: CTA B/L

• Abd: soft, NT, ND, +BS, no masses appreciated

• Rectal: no masses appreciated, guiaic neg

• Ext: FROM x4, 2+ x4

• Lymphatic: no lymphadenopathy appreciated

PHYSICAL EXAMdownstatesurgery.org

LABS• CBC: 6.7 / 11.5 / 36 / 436

• BMP: 145 / 4.5 / 108 / 28 / 15 / 1 / 95

• LFTs: 7.4 / 4.1 / 19 / 18 / 42 / 0.5

• Coags: 12.6 / 23.6 / 1

• RA ABG: 7.42 / 38.3 / 113 / 27.3 / 98.9 / 3

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• CXR WNL

• CT chestabdomen

RADIOLOGYdownstatesurgery.org

• Fungating, ulcerated, friable mass in distal 1/3 of the esophagus through the GE junction into the cardia of the stomach

• EUS probe could not be passed

• Pathology: moderately differentiated adenocarcinoma of GEJ origin

EGDdownstatesurgery.org

PET

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• Bronchoscopy, Endoscopy, Laparotomy, Transhiatal

esophagectomy with cervical anastomosis

• Operative Findings

▫ Endoscopy: near obstructing mass at 40cm

▫ Mass ~2cm above and below GEJ

▫ Celiac node negative on frozen section

Operative Interventiondownstatesurgery.org

• 6.5 X 5.5 cm GEJ/cardia adenocarcinoma

• Grade III, poorly differentiated

• Penetrates adventitia but no adjacent structures

• 2cm gastric margin

• 2/14 regional LN positive, celiac node neg, L. cervical node neg

• T3N1M0

• Chronic H. pylori gastritis

PATHOLOGYdownstatesurgery.org

• POW #1:▫ Extubated, Jej feeding, Esophagram: postop edema, no leak

• POW #2:▫ Tx to floor from SICU, difficulty w/ PO intake, failed S&S▫ modified barium swallow: persistent post op edema & near obstruction

at anastomosis• POW #3:

▫ Chemoport placed, esophageal dilatation performed• POW #4:

▫ Persistent difficulty w/ PO intake• POW #5:

▫ Rpt modified barium swallow persistent anastomotic obstruction, Rpt esophageal dilatation

• POW #6:▫ Rpt esophageal dilatation

• POW #7:▫ Rpt esophageal dilatation & stent placement

POSTOP COURSEdownstatesurgery.org

Management of

GEJ

Adenocarcinomas

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Presentation• Dysphagia

• Odynophagia

• Wt loss

• Dyspnea

• Cough

• Hoarseness

• Pain

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DIAGNOSIS

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CXR• Mediastinal or hilar lymphadenopathy

• Pulmonary infiltrates

• Lung mets

• Pulmonary effusion

Adult Chest Surgery

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ESOPHAGRAM• mucosal irregularity

and shouldering

• narrowing of the lumen,

and proximal dilatation

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CT Scan• Detect mets

• Cannot distinguish

tumor stage

• Low sensitivity in detecting nodal involvement

• Monitor tumor response to cytoreductive

therapy

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BRONCHOSCOPY• Assess involvement of tracheobronchial tree

▫ Widened carina

▫ External compression

▫ Tumor infiltration

▫ Fistulization

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Endoscopy

• Bx

• Detect other path

emedicine.medscape.com/article/277930-overview

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EUS• Only imaging that can

distinguish the layers of

the esophageal wall

• T staging 85% accurate

• N staging 75% accurate

▫ Up to 2cm from esophagus

• 1/3 non-traversable stricture

• Less accurate post-therapy

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PET• Detects mets not seen on CT

• No value in T staging

• Better for detecting higher nodes (cervical>thoracic>abdominal)

• Assess response to cytoreduction Tx

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Siewert ClassificationTumors of GEJ = tumors w/ centers w/in 5cm proximal

or distal to the cardia

• Type I▫ Distal esophagus

• Type II▫ True Ca of the cardia

• Type III▫ Subcardial gastric Ca

Stein et al 2000

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Etiology & Pathology

• Male predominance, 1.5 : 1 – 8:1, >Type I

• Type I: more likely to have long standing GERD, or esophageal hernia

• Higher incidence of H.pylori w/ Types II & III

• Lymphatic spread w/ Type I mediastinum & celiac axis

• Lymphatic spread w/ Types II & III celiac axis preferentially, also splenic hilus, & paraaortic

Stein et al 2000, Maingot 2007

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Staging of esophagus & GEJ Ca

Rvw of 4600 esophagectomy pts (13 institutions, 5

countries: Worldwide Esophageal Cancer

Collaboration)

7th edition of the AJCC Cancer Staging Manual 2009

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• T classification▫ Tis High-grade dysplasia▫ T1: invades lamina propria/submucosa but not beyond▫ T2: invading into but not beyond muscularis propria▫ T3: invades adventia but not adjacent structures▫ T4a Resectable cancer invades adjacent structures such as pleura,

pericardium,diaphragm▫ T4b Unresectable cancer invades adjacent structures such as aorta,

vertebral body,trachea• N classification

= Any periesophageal lymph node from cervical nodes to celiac nodes▫ N0: No regional lymph node metastases▫ N1: 1 to 2 positive regional lymph nodes▫ N2: 3 to 6 positive regional lymph nodes▫ N3: >7 positive regional lymph nodes

• M classification▫ M0 No distant metastases▫ M1 Distant metastases 7th edition of the AJCC Cancer Staging Manual 2009

Maingot 2007

TNM Classificationdownstatesurgery.org

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Surgical Approach - PreOp• Consider age – typically not done if >80 y/o

• Cardiopulmonary reserve

▫ FEV-1 : >2L is ideal; >1.25 for thoracotomy

▫ Clinical eval, EKG, echo

• Nutritional status

▫ Most predictive of postop complications (wt loss >20lb, albumin <3.5)

• Clinical staging

▫ Paralysis of diaphragm

▫ Bronchiotracheal involvement

▫ Malignant pleural effusion

Schwartz 2010

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Different Surgical Approaches• Ivor Lewis

▫ Abdominal/thoracic dissection▫ Thoracic esophagogastrostomy

• Left Thoracoabdominal

• Transhiatal▫ Cervical and upper midline incisions▫ Blind chest dissection▫ Cervical esophagogastrostomy

Feeding jejunostomy

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Abdominal Dissection

ACS 2009

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Esophageal Dissection

ACS

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Ivor Lewis

ACS 2009

• Abdominal/thoracic dissection

• Direct visualization

• Leak rate ~5%▫ Difficult to manage empyema

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Left Thoracoabdominal

ACS 2009

• Indicated for GEJ, distal esophageal, proximal stomach tumors ▫ especially if using

intestinal conduit

▫ obese

• Thoracic esophagogastrostomy

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Transhiatal

ACS 2009 & Maingot 2007

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• Tubularized or whole stomach▫ Preferred b/c blood supply▫ Proximity▫ Single anastomosis

• Colon▫ Stomach can’t be used Prior Sx, PUD scarring, tumor involvement

▫ L colon preferred b/c Diameter closer to that of esophagus, more length, less variation of blood

supply▫ Problems w/ L. colon most affected by diverticular Dz, IMA most affected by atherosclerosis

• Jejunum▫ Cannot replace entire esophagus▫ Free graft, pedicled graft, or Roux-en-Y

Reconstruction

Maingot 2007

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Creating the Gastric Tube

Don’t forget pyloromyotomy/pyloroplasty

ACS 2009

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Pitfalls in Surgical Management• Retrospective analysis of 117 pts w adenoCa of

proximal 1/3 of the stomach 1961-1970

• Esophagitis, hiatal hernia, achalasia should not delay suspicion of Ca

• Avoid microscopic tumor extension at the esophageal margin (suture line dehiscence 5/7 deaths) => frozen section? & 6cm esophageal margin

Alfonso et al 1977

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Surgical Approach –Which way do I go?

• Transhiatal esophagectomy (THE) is may be safer• One major incision instead of 2• Shorter OR time

• Transthoracic esophagectomy (TTE) may be a better oncological procedure

• Extended lymph node dissection in the posterior mediastinum

• Better for tumors close to tracheobronchial tree & after neoadjuvant Tx especially mid & upper esophagus

Maingot 2007

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Outcomes after Transhiatal & Transthoracic Esophagectomy

Chang AC et al. Ann Thorac Surg 2008

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Pts s/p THE had:

• Lower operative mortality (30 days)▫ 6.7% vs 13.1%, p = 0.009

• Trend towards higher 5-yr survival ▫ No statistically significant difference

• More likely to require endoscopic dilatation w/in 6months▫ 43.1% vs 34.5%, p = 0.02

Outcomes after Transhiatal & Transthoracic Esophagectomy

Chang AC et al. Ann Thorac Surg 2008

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Extended TTE vs Limited THE for AdenoCa of the mid/distal Esophagus

• 1994-2000; randomly assigned 220 pts w/ THE (n=95) or TTE (n=110); 15 pts excluded b/c unresectable

• 5-yr survival THE 34% vs TTE 36%, p = 0.71

• Survival benefit 14% in Type I tumor w/ TTE (51% vs 37%, p = 0.33)▫ Not seen in pts w/ Type II tumor, no positive nodes, or >8 + nodes

• TTE higher perioperative morbidity but no difference in mortality

Omloo et al. Ann Surg 2007.

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Neoadjuvant Chemo or ChemoRT

• Potential benefit of downstaging

• Toxicity may delay or cancellation of resection

Adult chest surgery

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• Kelsen et al ‘98▫ American multi-institutional trial▫ Randomized 440pts Sx alone vs neoadjuvant chemo followed by Sx▫ 3 cycles 5-FU and cisplatin; Sx 2-4 wks later; 2 cycles postop▫ No difference in morbidity, mortality, or survival

• Urba et al 2001▫ 100 patients randomized to preoperative chemoradiation or surgery

alone▫ Median survival was about 18 months in both groups, although there

was a trend toward improved survival at 3 years (30% versus 16%; not statistically significant).

Neoadjuvant Chemo or ChemoRT

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• 10 randomized trials 1983-2006▫ 1209 pts compared neoadjuvant chemoRT vs Sx

alone▫ 6 studies SCC only, 1 adenoCa only, 3 both

• 8 randomized trials 1982-1992▫ 1724 pts neoadjuvant chemotherapy vs Sx alone▫ 7 SCC only, 2 SCC & adenoCa

Neoadjuvant Chemo or ChemoRT

Gebski et al. Lancet Oncology. 2007; 8:226-34

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The hazard ratio for all-cause mortality is 0·90 (0·81–1·00) for patients receiving chemotherapy and 0·81 (0·70–0·93) for patients receiving neoadjuvant chemoradiotherapy

Neoadjuvant Chemo or ChemoRTGebski et al. Lancet Oncology. 2007

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Adjuvant Chemo & ChemoRT

• Better local regional control

• Poorly studied

• No statistically significant change in 5-year survival

Maingot 2007

Adult Chest Surgery

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Follow-Up• Look for locoregional recurrence and metastatic disease.

• First 3 years f/u every 3 months then subsequently every 4 to 6 months

• Each visit should include:▫ history and physical▫ complete blood count and liver panel▫ computed tomography of the chest and abdomen▫ Radiographic evidence of possible recurrence warrants

biopsy to confirm diagnosis

Cameron 2008

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SUMMARY• Goal of surgery is R0 resection

• No proven significant difference in 5 yr survival with transthoracic vs transhiatal approach

• No proven significant difference in 5 yr survival with neoadjuvant or adjuvant therapy▫ But there may be some benefit?

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References• Krasna Mark, Ebright Michael, "Chapter 10. Overview" (Chapter). Sugarbaker DJ, Bueno R,

Krasna MJ, Mentzer SJ, Zellos L: Adult Chest urgery:http://www.accesssurgery.com/content.aspx?aID=5285623.

• ACS Surgery: Principles & Practice 2009• Sabiston Textbook of Surgery, 18th ed. 2007• Schwartz's Principles of Surgery - 9th Ed. (2010) • Maingot's Abdominal Operations, 11th Edition. 2007• Cameron: Current Surgical Therapy, 9th ed. 2008• Stein HJ, Feith M, Siewert JR. cancer of the esophagogastric junction. Surgical

Oncology.2000.9(1):35-41.• Edge SB, Byrd DR, Compton CC, et al., eds. AJCC CancerStaging Manual. 7th ed. New York:

Springer-Verlag; 2009. p.103–15.• Alfonso et al. Am Journal Surg. 1977. pg.326-330• Chang AC et al. Ann Thorac Surg 2008: 85:424-9• Goldfaden et al. J Thorac Cardiovasc Surg. 1986 Feb; 91(2):242-7. • Omloo et al. Ann Surg 2007. Dec;246(6):992-1000• Kelsen DP, Ginsberg R, Pajak TF, et al: Chemotherapy followed by surgery compared with

surgery alone for localized esophageal cancer. N Engl J Med 339:1979–84, 1998.• Urba SG, Orringer MB, Turrisi A, et al. Randomized trial of preoperative chemoradiation versus

surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol 2001;19:305–313

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ThanK You

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